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CORK Bibliography: Substance Abuse and Chronic Mental Illness

102 citations. January 2005 to present

Prepared: January 2008

Aguilar MC; Gurpegui M; Diaz FJ; De Leon J. Nicotine dependence and symptoms in schizophrenia: Naturalistic study of complex interactions. British Journal of Psychiatry 186: 215-221, 2005. (27 refs.)

Background: Smoking may have a beneficial effect on either schizophrenic symptoms or antipsychotic side-effects, but studies are hampered by the lack of control of confounding factors. Aims: To explore the self-medication hypothesis in a large sample of stable outpatients with schizophrenia. Method Symptoms, assessed with the Positive and Negative Syndrome Scale (PANSS), and number of hospitalizations were compared in 250 out-patients with DSM - IV schizophrenia classified into three categories: highly dependent smokers, mildly dependent smokers and non-smokers. Log-linear analysis was used to control for potential confounding and interacting variables. Results: High PANSS total scores and positive symptoms were less frequent in mildly dependent smokers than in nonsmokers or highly dependent smokers. The highly dependent smokers had the worst outcome. Conclusions: The data do not generally support the self-medication hypothesis but rather suggest a complex interaction between nicotine dependence and schizophrenic symptoms. Declaration of interest None. Funding detailed in Acknowledgements.

Barrowclough C; Ward J; Wearden A; Gregg L. Expressed emotion and attributions in relatives of schizophrenia patients with and without substance misuse. Social Psychiatry and Psychiatric Epidemiology 40(11): 884-891, 2005. (26 refs.)

OBJECTIVE: To test the hypotheses that carers of patients with schizophrenia (single diagnosis) and schizophrenia and co-occurring drug or alcohol misuse (dual diagnosis) will differ in terms of expressed emotion (EE) and their attributions for patient problems. METHOD: In a cross-sectional study, two samples of 42 single- and dual-diagnosis carers are compared in terms of EE and attributions. Patient symptoms are assessed to control for differences other than substance misuse. RESULTS: The study supports the hypothesis that high-EE, dual-diagnosis carers tend to see patient problems as more blaming (internal, controllable and personal) than do single-diagnosis patients. This difference was particularly marked when making causal ascriptions for deficit behaviours. Although there were no differences in overall EE levels in the two groups, there were significantly more carers who were rated as hostile and rejecting in thedual-diagnosis group. CONCLUSIONS: The findings highlight the importance of family intervention for this patient group.

Benda BB. Survival analyses of social support and trauma among homeless male and female veterans who abuse substances. American Journal of Orthopsychiatry 76(1): 70-79, 2006. (82 refs.)

This appears to be the 1st study of gender differences in how well various forms of trauma and social support predict homeless substance abusers' tenure in the community without rehospitalization. Sexual and physical abuses at different stages of the life span, combat exposure, and recent traumatic events were analyzed with social support factors via Cox's proportional hazard model of survival in a 2-year follow-up. The survival models showed similarities and dissimilarities in predictors of tenure in the community for women compared to men among homeless veterans. Traumata and related factors (e.g., depression and suicidal thoughts) were more potent (negative) predictors of tenure, and family and friends were more important social supports, for women than for men. Men's tenure was more positively associated with job satisfaction and more negatively related to substance abuse, combat exposure, cognitive impairments, aggression, and physical health problems. The intervention implications of these findings are discussed.

Berkman A; Pilowsky DJ; Zybert PA; Leu CS; Sohler N; Susser E. The impact of substance dependence on HIV sexual risk-reduction among men with severe mental illness. AIDS Care 17(5): 635-639, 2005. (9 refs.)

We explored the impact of substance dependence on the efficacy of an HIV sexual risk reduction intervention previously shown to be effective among men with severe mental illness by comparing rates of high-risk sexual behaviors among men with (n=26) and without (n=31) a lifetime history of substance dependence. We sub-divided subjects by alcohol and drug dependence status, comparing each intervention sub-group to the corresponding control sub-group. At each follow-up interval (six, 12 and 18 months), the intervention group as a whole and the non-substance dependent participants showed a significant reduction in risk; the substance-dependent men showed no difference from controls. These data suggest that among men with severe mental illness, substance dependence may be a further impediment to HIV risk reduction.

Bobier C; Warwick M. Factors associated with readmission to adolescent psychiatric care. Australian and New Zealand Journal of Psychiatry 39(7): 600-606, 2005. (41 refs.)

Objective: The aim of this study is to identify factors associated with readmission to adolescent psychiatric inpatient care, in the context of a relapsing major mental illness. Method: Data were obtained from 71 patients admitted to an adolescent psychiatric inpatient unit over a 2-year period. Patients who were rehospitalized within 12 months of discharge were compared with patients who had only one admission during the study period with respect to diagnosis, age of first admission, history of child sexual abuse (CSA) and the events precipitating admission. Results: Medication non-adherence and a history of CSA were positively and independently associated with relapse readmission, while a trend emerged among readmitted patients toward younger age at first psychiatric hospitalization. A negative association was found between readmission and the experience of personal loss. Readmission was not related to DSM-IV axis I or axis II diagnosis, including substance abuse. Conclusions: The association, in an adolescent sample, of medication non-adherence and relapse readmission is consistent with findings from numerous adult studies, as is the trend toward younger age of first admission. The relationship of a history of CSA to readmission has attracted little previous research and the finding of a positive association suggests that further investigation of a history of CSA in this context is warranted. The implications of these findings and suggestions for further research are discussed.

Bozikas VP; Niopas I; Kafantari A; Kanaze FI; Gabrieli C; Melissidis P et al. No increased levels of the nicotine metabolite cotinine in smokers with schizophrenia. (review). Progress in Neuro-Psychopharmacology & Biological Psychiatry 29(1): 1-6, 2005. (47 refs.)

The prevalence of smoking cigarettes has repeatedly been found to be greater in schizophrenia as compared with other psychiatric patients and the general population. Patients with schizophrenia have been found to engage in heavy smoking and consumption of higher doses of nicotine, probably by deeper inhalation of cigarettes. The aim of the current study was to assess nicotine exposure through smoking by measuring urinary cotinine, the major nicotine metabolite, in a group of smokers from Greece of smokers with schizophrenia and smokers from the general population. Participants were current smokers and belonged to one of two groups: 35 patients with schizophrenia and 48 healthy controls matched in age, education, and gender. The quantitative analysis of cotinine. the major metabolite of nicotine. in urine samples was performed by a modified high performance liquid chromatography (HPLC). Patients with schizophrenia who smoke presented a significantly larger time interval between last cigarette smoked and urine sample collection, as well as a significantly higher average number of cigarettes consumed daily than normal smokers. Urinary cotinine levels of patients with schizophrenia who smoke did not significantly differ from that of normal smokers when adjusted for average number of cigarettes per day and time interval between last cigarette smoked and urine collection. These results suggest that patients with schizophrenia did not present higher nicotine exposure through smoking compared with smokers from the community. The pharmacokinetic or pharmacodynamic properties of nicotine, as well as patient medications of the patients may explain our findings.

Broome MR; Woolley JB; Tabraham P; Johns LC; Bramon E; Murray GK et al. What causes the onset of psychosis? Schizophrenia Research 79(1): 23-34, 2005. (100 refs.)

it has become increasingly clear that the simple neurodevelopmental model fails to explain many aspects of schizophrenia including the timing of the onset, and the nature of the abnormal perceptions. Furthermore, we do not know why some members of the general population have anomalous experiences but remain well, while others enter the prodrome of psychosis, and a minority progress to frank schizophrenia. We suggest that genes or developmental damage result in individuals vulnerable to dopamine deregulation. In contemporary society, this is often compounded by abuse of drugs such as amphetamines and cannabis, which then propel the individual into a state of dopamine-induced misinterpretation of the environment. Certain types of social adversity such as migration and social isolation, as well as affective change can also contribute to this. Thereafter, biased cognitive appraisal processes result in delusional interpretation of the abnormal perceptual experiences. Thus, a plausible model of the onset of psychosis needs to draw not only on neuroscience, but also on the insights of social psychiatry and cognitive psychology.

Brown ES. Introduction. The challenges of dual diagnosis: Managing substance abuse in severe mental illness. (editorial). Journal of Clinical Psychiatry 67(Supplement 7): 3-4, 2006. (3 refs.)

Brunette MF; Drake RE; Xie HY; McHugo GJ; Green AI. Clozapine use and relapses of substance use disorder among patients with co-occurring schizophrenia and substance use disorders. Schizophrenia Bulletin 32(4): 637-643, 2006. (48 refs.)

Background: Previous correlational research with schizophrenic patients has suggested that the second-generation antipsychotic medication clozapine helps to induce remissions of substance use disorder in patients with co-occurring psychosis and substance abuse. This research, however, could be biased by selection factors. Studying patients who are currently in substance abuse remission could control for level of motivation to stop using substances and other methodological confounds. Methods: To test whether clozapine was associated with prevention of substance abuse relapses, we examined patients with schizophrenia or schizoaffective disorder who were in their first 6-month remission of substance use disorder during a prospective 10-year follow-up study. All patients received yearly multimodal assessments of substance use. Antipsychotic medications were prescribed by community doctors as part of usual clinical care. Results: Patients using clozapine at the first 6-month period of substance abuse remission (n = 25) were much less likely to relapse over the next year compared with those on other antipsychotic medications (n = 70): 8.0% vs 40.0%, chi(2) = 8.73 (df = 1), P = .003. Although medication assignment was not randomized, several potential confounders were similar between the groups. Conclusion: Clozapine should be considered for the treatment of patients with schizophrenia and co-occurring substance use disorder to prevent relapses to substance abuse.

Public Domain

Brunette MF; Mueser KT. Psychosocial interventions for the long-term management of patients with severe mental illness and co-occurring substance use disorder. Journal of Clinical Psychiatry 67(Supplement 7): 10-17, 2006. (59 refs.)

People with severe mental illness and co-occurring substance use disorders, also referred to as dual disorders, experience worse outcomes over the long term than people without co-occurring substance abuse. Integrated treatment of both disorders has been shown to be more effective than separate treatments offered in parallel or in sequence. The principles and strategies of integrated dual disorder treatment (IDDT) include integration of treatments for the mental illness and the addiction, use of strategies to engage people in treatment, use of pharmacologic and psychosocial interventions that are matched to the patient's stage of change, and use of a long-term perspective. The stages of change, the stages of treatment, and the psychosocial strategies used at each stage of treatment are outlined.

Buckley PF. Prevalence and consequences of the dual diagnosis of substance abuse and severe mental illness. Journal of Clinical Psychiatry 67(Supplement 7): 5-9, 2006. (37 refs.)

The co-occurrence of a severe mental illness and a substance use or abuse disorder is common in the United States as well as internationally and could be considered as more the expectation than the exception when assessing patients with serious mental illness. Substance use disorders can occur at any phase of the mental illness, perhaps even inducing psychosis. Causes of this comorbidity may include self-medication, genetic vulnerability, environment or lifestyle, underlying shared origins, and/or a common neural substrate. The consequences of dual diagnosis include poor medication compliance, physical comorbidities and poor health, poor self-care, increased suicide risk or aggression, increased sexual behavior, and possible incarceration. All of these factors contribute to a greater health burden, which reduces the health care system's capacity to adequately treat patients. Therefore, screening, assessment, and integrated treatment plans for dual diagnosis that can address both the addiction disorder and the mental illness are recommended in order to provide accurate treatment, aftercare, and other health care to accommodate patients' social and vocational needs.

Cannon M; Clarke MC. Risk for schizophrenia: Broadening the concepts, pushing back the boundaries. Schizophrenia Research 79(1): 5-13, 2005. (107 refs.)

This paper gives an overview of environmental risk factors for schizophrenia. The presence of certain biological and psychosocial factors at certain points in the lifespan has been linked to later development of schizophrenia. These include prenatal infection, obstetric complications, childhood developmental impairments, early rearing environment, adolescent cannabis use, urban dwelling and membership of a minority population. Some of these risk factors operate on an individual level and some on a societal level but all need to be considered in the context of schizophrenia as a lifelong brain disorder. Research interest in schizophrenia, especially neuro-imaging interest, is shifting to ever earlier stages of the disease process and so the journey to discover the causes of schizophrenia is likely to take us right back to the beginning of development.

Caton CLM; Hasin DS; Shrout PE; Drake RE; Dominguez B; Samet S et al. Predictors of psychosis remission in psychotic disorders that co-occur with substance use. Schizophrenia Bulletin 32(4): 618-625, 2006. (45 refs.)

Objective: To examine rates and predictors of psychosis remission at 1-year follow-up for emergency admissions diagnosed with primary psychotic disorders and substance-induced psychoses. Method: A total of 319 patients with comorbid psychosis and substance use, representing 83% of the original referred sample, were rediagnosed at 1 year postintake employing a research diagnostic assessment. Remission of psychosis was defined as the absence of positive and negative symptoms for at least 6 months. Likelihood ratio chi-square tests and multivariate logistic regression were the main means of analysis. Results: Of those with a baseline diagnosis of primary psychotic disorder, 50% were in remission at 1 year postintake, while of those with a baseline diagnosis of substance-induced psychosis, 77% were in remission at this time point. Lower Positive and Negative Syndrome Scale (PANSS) symptom levels at baseline, better premorbid functioning, greater insight into psychosis, and a shorter duration of untreated psychosis predicted remission at 1 year in both diagnostic groups. No interaction effects of baseline predictors and diagnosis type were observed. A stepwise multivariate logistic regression holding baseline diagnosis constant revealed the duration of untreated psychosis (odds ratio [OR] = 0.97; 95% confidence interval [CI] = 0.95, 0.997), total PANSS score (OR = 0.98; 95% CI = 0.97, 0.987), Premorbid Adjustment Scale score (OR = 0.13; 95% CI = 0.02, 0.88), and Scale to Assess Unawareness of Mental Disorders unawareness score (OR = 0.84; 95% CI = 0.71, 0.993) as key predictors of psychosis remission. Conclusions: The association of better premorbid adjustment, a shorter duration of untreated psychosis, better insight into psychotic symptoms, and lower severity of psychotic symptoms with improved clinical outcome, reported previously in studies of schizophrenia, generalizes to psychosis remission in psychotic disorders that are substance induced.

Public Domain

Comtois KA; Tisdall WA; Holdcraft LC; Simpson T. Dual diagnosis: Impact of family history. American Journal on Addictions 14(3): 291-299, 2005. (33 refs.)

Psychiatric outpatients with severe and persistent mental illness and a current or past substance use disorder (N = 89) were interviewed. Information from the Family Informant Schedule and Criteria was configured in three ways to capture the degree of familial substance abuse: biological parents only, all first-degree biological relatives, and all caregivers. All three configurations predicted the severity of lifetime drug abuse on the Inventory of Drug Use Consequences, controlling for any gender and non-substance-related Axis I diagnosis. Differences in means represent low to very low substance abuse severity for those without family history and low to medium severity for those with family history. The clinical implications are discussed.

de Leon J; Diaz FJ. A meta-analysis of worldwide studies demonstrates an association between schizophrenia and tobacco smoking behaviors. (review). Schizophrenia Research 76(2-3): 135-157, 2005. (111 refs.)

A meta-analysis of worldwide studies, found by a 10-year literature follow-up and/or by searching PubMed, was performed. Forty-two studies across 20 nations consistently demonstrated an association between schizophrenia and current smoking (weighted average odds ratio, OR=5.9; 95% confidence interval, CI 4.9-5.7). In 32 male studies across 18 nations, the weighted average OR was 7.2 (CI, 6.1-8.3). In 25 female studies across 15 nations, the weighted average OR was 3.3 (CI, 3.03.6). The association between schizophrenia and current smoking remained after using severe mentally ill controls (18 studies across 9 countries, weighted average OR was 1.9, CI 1.7-2.1) and controlling for other variables (3 studies, adjusted ORs ranged 2-3). Heavy smoking (6 studies across 4 countries, ORs ranged 1.9-6.4) and high nicotine dependence were more frequent in smokers with schizophrenia versus the general population. There was no consistent evidence that heavy smoking or high nicotine dependence was more frequent in smokers with schizophrenia versus severe mentally ill controls. Cessation rates were lower in schizophrenia smokers versus the general population. Schizophrenia patients had a higher prevalence of ever smoking than the general population (9 studies across 6 countries, weighted average OR=3.1, CI 2.4-3.8) and than severe mentally ill patients (5 studies across 5 countries, OR=2.0, CI 1.6-2.4). Moreover, in two studies adjusting for confounders schizophrenia patients had an increased risk of starting daily smoking than controls. Thus, people who are going to develop schizophrenia have risk factors that make them more vulnerable to start smoking.

de Leon J; Susce MI; Diaz FJ; Rendon DM; Velasquez DM. Variables associated with alcohol, drug, and daily smoking cessation in patients with severe mental illnesses. Journal of Clinical Psychiatry 66(11): 1447-1455, 2005. (56 refs.)

Background. Co-occurrence of substance use disorders and severe mental illnesses (SMIs) is a major U.S. public health issue, although the role of tobacco is usually neglected. This study explored variables associated with alcohol, drug, and smoking cessation in a naturalistic setting. Method: Logistic regression was used to study variables associated with cessation of alcohol and drug use disorder and daily smoking in 560 SMI inpatients and outpatients from central Kentucky facilities. Patients with a lifetime history of alcohol or drug use disorder were considered to be in cessation if they had not suffered from abuse or dependence during the last year. Alcohol and drug use disorder diagnoses were determined using the Clinician Rating of Alcohol and Drug Use Disorder. Patients were recruited from July 2000 to March 2003. Results: The cessation rates for alcohol and drug use disorders were, respectively, 44% (95% Cl = 39% to 49%) and 46% (Cl = 40% to 51%); these were higher than the daily cigarette smoking cessation rate of 10% (Cl = 7% to 13%). Drug use disorders (p <= .02), outpatient status (p < .001), and having a medical complication of obesity (diabetes mellitus, hypertension, or hyperlipidemia; p < .001) were significantly associated with alcohol cessation. Alcohol use disorder (p < .001), starting treatment with psychiatric medications after 33 years of age (p <\ .001), taking these medications for 14 years or more (p = .02), schizophrenia diagnosis (p < .001), outpatient status (p = .03), and obesity (p = .04) were significantly associated with drug cessation. Cessation of daily smoking was associated with hypertension (p = .02), late start of treatment with psychiatric medications (> 33 years old; p = .01), and lack of lifetime drug abuse (p < .001). Conclusions: These results are limited by the cross-sectional and naturalistic design but suggest that public health experts, researchers, and clinicians need to mindfully address smoking cessation in patients with SMIs. Clinicians may want to consider that medical illnesses may motivate patients with SMIs to stop substance abuse and that patients with SMIs who abuse both alcohol and drugs rarely stop abusing just one of them.

Deas D. Adolescent substance abuse and psychiatric comorbidities. Journal of Clinical Psychiatry 67(Supplement 7): 18-23, 2006. (32 refs.)

Substance use disorders have a serious impact on adolescents because these disorders have high prevalence rates and frequent associations with psychiatric disorders. Surveys of adolescent behaviors and substance use show that alcohol is the most common substance abused by adolescents. Despite the high rates of current alcohol use and binge drinking among adolescents, current diagnostic criteria are problematic. Adolescents may have a developing problem with substance dependence but not meet criteria for either substance abuse or dependence. At-risk adolescents, called "diagnostic orphans," may meet only 1 or 2 criteria for alcohol dependence and no abuse criteria and therefore do not receive an alcohol use disorder diagnosis from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Adolescents with substance use disorders tend to have higher rates of comorbid psychiatric disorders and are more likely to report a history of trauma and physical and/or sexual abuse than adolescents without a substance use disorder. In addition, psychiatric disorders in adolescents often predate the substance use disorder. Once the substance use disorder develops, the psychiatric disorder may be further exacerbated.

Deshmukh A; Rosenbloom MJ; De Rosa E; Sullivan EV; Pfefferbaum A. Regional striatal volume abnormalities in schizophrenia: Effects of comorbidity for alcoholism, recency of alcoholic drinking, and antipsychotic medication type. Schizophrenia Research 79(2-3): 189-200, 2005. (46 refs.)

Striatal structures form critical nodes of multiple circuits that are implicated in the pathophysiology of schizophrenia and alcoholism. Here, we examined the separate and combined effects of schizophrenia and alcoholism and effects of medication type and drinking recency on striatal volumes. Accordingly, we measured caudate nucleus, putamen, and nucleus accumbens in 27 schizophrenic, 25 alcohol-dependent, 19 comorbid (schizophrenia and alcohol dependence or abuse), and 51 age-matched control men. Schizophrenics were classified by antipsychotic medication (typical or atypical), and alcoholics were classified by recency of sobriety. All measured structures were smaller in the patient groups than the control group. The caudate deficit was comparable across groups, whereas putamen and nucleus accumbens deficits were greater in schizophrenia than alcoholism; comorbids fell between these groups. Schizophrenic patients treated with atypical medication showed greater volume deficits in the putamen than those treated with typical medication. Recently sober (<3 weeks) alcoholics had greater deficits in nucleus accumbens than longer sober drinkers. In conclusion, caudate, putamen, and nucleus accumbens exhibited different patterns of volume deficit in patients with alcoholism and schizophrenia alone, with no evidence for compounded deficits in comorbid patients. Further, these cross-sectional data provide indirect support for at least partial recovery of nucleus accumbens volume with sobriety in alcoholics, regardless of schizophrenia comorbidity.

Di Forti M; Murray RM. Cannabis consumption and risk of developing schizophrenia: Myth or reality? (editorial). Epidemiologia E Psichiatria Sociale 14(4): 184-187, 2005. (32 refs.)

Drake RE; McHugo GJ; Xie HY; Fox M; Packard J; Helmstetter B. Ten-year recovery outcomes for clients with co-occurring schizophrenia and substance use disorders. Schizophrenia Bulletin 32(3): 464-473, 2006. (57 refs.)

The long-term courses of people with schizophrenia and of those with substance use disorder have been studied separately and extensively. The long-term course of clients with co-occurring schizophrenic and substance use disorders has, however, not been examined. This article reports 10-year outcomes for 130 clients with co-occurring schizophrenic and substance use disorders in the New Hampshire Dual Diagnosis Study. In addition, we report on 6 "recovery outcomes," identified by dual diagnosis clients, as examples of positive coping behaviors. Longitudinal data were modeled using generalized estimating equation (GEE) methods. Participants improved steadily over 10 years in the outcome domains of symptoms, substance abuse, institutionalization, functional status, and quality of life. Further, at the 10-year follow-up, substantial proportions were above cutoffs selected by dual diagnosis clients as indicators of recovery: 62.7% were controlling symptoms of schizophrenia; 62.5% were actively attaining remissions from substance abuse; 56.8% were in independent living situations; 41.4% were competitively employed; 48.9% had regular social contacts with non-substance abusers; and 58.3% expressed overall life satisfaction. These 6 outcomes were only weakly interrelated over time, suggesting that recovery, as defined by clients, is a multidimensional concept. Overall, the 10-year findings on recovery outcomes provide a hopeful long-term perspective for dual diagnosis clients.

Drake RE; Wallach MA; McGovern MP. Future directions in preventing relapse to substance abuse among clients with severe mental illnesses. Psychiatric Services 56(10): 1297-1302, 2005. (66 refs.)

The authors review the literature on substance use disorders among persons with severe mental illnesses, including the other papers in this special section on relapse prevention, and suggest future directions. Although prevention of relapse to substance abuse has a well-developed theoretical and empirical base, this perspective has rarely been applied to persons with co-occurring severe mental illness. Research indicates that clients with co-occurring disorders are highly prone to relapse to substance abuse, even after they have attained full remission. Their risk factors include exacerbations of mental illness, social pressures within drug-using networks, lack of meaningful activities and social supports for recovery, independent housing in high-risk neighborhoods, and lack of substance abuse or dual diagnosis treatments. The evidence in hand suggests several steps: developing healthy and protective environments that are experienced as nurturing of recovery; helping people make fundamental changes in their lives, such as finding satisfying jobs, abstinent friends, networks of people who are in the process of recovery, and a sense of meaning; providing specific and individualized treatments for mental illnesses, substance use disorders, and other co-occurring problems; and developing longitudinal research on understanding and preventing relapse that addresses social context as well as biological vulnerabilities and cognitive strategies.

Ejaz S; Lim CWCampo-Arias A Diaz-Martinez LA Rueda-Jaimes GE Rueda-Sanchez M Farelo-Palacin D Diaz FJ et al. Smoking is associated with schizophrenia, but not with mood disorders, within a population with low smoking rates: A matched case-control study in Bucaramanga, Colombia. Schizophrenia Research 83(2-3): 269-276, 2006. (28 refs.)

When comparing current smoking in schizophrenia patients versus the general population, the average odds ratio (OR) was 5.3 in a meta-analysis of 42 studies from 20 nations. Limited tobacco access can eliminate this strong association in some nations. Out of the 42 ORs, 37 were significantly higher than 1. Of the 5 non-significant ORs, three came from, Colombian studies comparing current smoking prevalences in schizophrenia versus those in the general population (18%). However, the 3 ORs were not adjusted for confounders. We hypothesized that the association between schizophrenia and smoking is so strong that it can be detected in populations with limited access to smoking after carefully controlling for confounders. Of the three Colombian studies, one included 73 schizophrenia patients (DSM-IV schizophrenia or schizoaffective disorder) and 111 patients with mood disorders (DSM-IV bipolar or major depressive disorders). The current study matched each of these patients with 2 controls from the general population and performed more sophisticated statistical analyses. Prevalences of current smoking were 26% for schizophrenia patients and 10% for their matched controls (adjusted Mantel-Haenszel OR = 3.1, 95% CI, 1.4-6.8), and 7% for patients with mood disorders and 12% for their matched controls (adjusted Mantel-Haenszel OR = 0.62; CI, 0.28-1.4). The previously observed lack of association between schizophrenia and current smoking was due to lack of control of important confounding variables because of the absence of a control group. This re-analysis, which used a careful matching that controlled for confounders, suggests that the association between schizophrenia and smoking behaviors can stand in populations with low monetary income and low smoking rates. This study also suggests that the association between severe mood disorders (bipolar and major depression) and smoking is not as strong as that observed between schizophrenia and smoking, and may not be observable in countries where people have limited economic resources.

Elbogen EB; Swanson JW; Swartz MS; Van Dorn R. Medication nonadherence and substance abuse in psychotic disorders: Impact of depressive symptoms and social stability. Journal of Nervous and Mental Disease 193(10): 673-679, 2005. (48 refs.)

Although studies have consistently shown a strong relationship between medication nonadherence and substance abuse in psychotic disorders, less is understood about the mechanisms underlying this relationship. The purpose of this study was to examine whether the relationship between substance abuse and medication nonadherence in psychosis is mediated by depressive symptoms and social stability. Participants interviewed (N = 528) were adults with schizophrenia and related disorders receiving public mental health services in four US states. Multivariate analyses showed substance abuse, depressive symptoms, and living stability each contributed to medication nonadherence; thus, the relationship between substance abuse and medication adherence in psychotic disorders did not appear to be mediated by the selected variables. Instead, a robust association between depressive symptoms and medication adherence was found, attesting to the utility of assessing for depression when evaluating adherence among people with psychosis. Living instability was common and related to medication nonadherence, too, warranting further investigation.

Esterberg ML; Compton MT. Smoking behavior in persons with a schizophrenia-spectrum disorder: A qualitative investigation of the transtheoretical model. Social Science & Medicine 61(2): 293-303, 2005. (53 refs.)

Smoking rates among persons with schizophrenia are up to three times the rates of the general US population, and research has shown that it is difficult to design cessation programs for people with schizophrenia that take into account their various cognitive and social deficits. More research is needed on the attitudes and priorities of people with schizophrenia in order to design and implement effective smoking cessation programs. Additionally, more research should be conducted with first-episode psychosis and chronic schizophrenia patients to investigate possible differences between these two groups. The purpose of this study, conducted in Atlanta, USA, was to use qualitative methodology to assess the Transtheoretical Model (TTM) in the context of smoking behavior in a sample of participants with schizophrenia-spectrum disorders. Data were obtained via interviews with 12 participants with either first-episode or chronic schizophrenia-spectrum disorders who smoked cigarettes. Differences between the two subsets of the sample were assessed. Results clustered into the following prevalent themes: (1) pros and cons of smoking; (2) beliefs about smoking cessation; (3) external influences on smoking and quitting; and (4) negative attitudes toward nicotine replacement therapies (NRT). Findings indicate that the majority of participants were in the precontemplation stage of quitting smoking, and that the primary advantages of smoking for this sample were relief from anxiety and negative symptoms. Important differences were found between chronic and first-episode participants in the areas of readiness-to-quit and beliefs about smoking cessation. Other findings indicate a lack of cessation programs offered to this sample, and overall negative attitudes toward NRT. Future interventions should take into account the reported pros and cons of smoking in this population, as well as other beliefs and attitudes regarding smoking behavior.

Evins AE; Cather C; Deckersbach T; Freudenreich O; Culhane MA; Olm-Shipman CM et al. A double-blind placebo-controlled trial of bupropion sustained-release for smoking cessation in schizophrenia. Journal of Clinical Psychopharmacology 25(3): 218-225, 2005. (52 refs.)

The objective of this study was to examine the efficacy of bupropion for smoking cessation in patients with schizophrenia. Adults with schizophrenia who smoked more than 10 cigarettes per day and wished to try to quit smoking were recruited from community mental health centers, enrolled in a 12-week group cognitive behavioral therapy intervention, and randomly assigned to receive either bupropion sustained-release 300 mg/d or identical placebo. Fifty-three adults, 25 on bupropion and 28 on placebo, were randomized, completed at least 1 postbaseline assessment and were included in the analysis. The primary outcome measures were 7-day point prevalence abstinence in the week after the quit date (week 4) and at the end of the intervention (week 12). Subjects in the bupropion group were significantly more likely to be abstinent for the week after the quit date (36% [9/25] vs. 7% [2/28], P = 0.016) and at end of the intervention (16% [4/25] vs. 0%, P = 0.043). Subjects in the bupropion group also had a higher rate of 4-week continuous abstinence (weeks 8-12) (16% [4/25] vs. 0%, P = 0.043) and a longer duration of abstinence (4.2 [3.2] weeks vs. 1.8 [0.96] weeks, t = 2.30, P = 0.037). The effect of bupropion did not persist after discontinuation of treatment. Subjects in the bupropion group had no worsening of clinical symptoms and had a trend toward improvement in depressive and negative symptoms. We conclude that bupropion does not worsen clinical symptoms of schizophrenia and is modestly effective for smoking cessation in patients with schizophrenia. The relapse rate is high after treatment discontinuation.

Ferdinand RF; Sondeijker F; van der Ende J; Selten JP; Huizink A; Verhulst FC. Cannabis use predicts future psychotic symptoms, and vice versa. Addiction 100(5): 612-618, 2005. (37 refs.)

Aims: To assess if cannabis use is a risk factor for future psychotic symptoms, and vice versa, in adolescents and young adults from the general population. Design: Cohort study. Setting/participants: 'Zuid Holland' study, a 14-year follow-up study of 1580 initially 4-16-year-olds who were drawn randomly from the Dutch general population. Because cannabis use is generally condoned in the Netherlands, false-negative reports of cannabis use may occur less frequently than in countries with stricter drug policies, which supports the value of the present study. Measurements: Life-time cannabis use and psychotic symptoms, assessed with the Composite International Diagnostic Interview (CIDI). Findings: Cannabis use, in individuals who did not have psychotic symptoms before they began using cannabis, predicted future psychotic symptoms (hazard ratio = 2.81; 95% confidence interval = 1.79-4.43). However, psychotic symptoms in those who had never used cannabis before the onset of psychotic symptoms also predicted future cannabis use (hazard ratio = 1.70; 95% confidence interval = 1.13-2.57). Conclusions: The results imply either a common vulnerability with varying order of onset or a bi-directional causal relationship between cannabis use and psychosis. More research on patterns and timings of these relationships is needed to narrow down the possibilities.

Fergusson DM; Horwood J; Ridder EM. Mirkin refuted: Reasons for believing that the association between cannabis use and risk of psychosis is probably causal. (letter). Addiction 100(5): 715, 2005. (9 refs.)

Foley SR; Kelly BD; Clarke M; McTigue O; Gervin M; Kamali M; Larkin C; O'Callaghan E; Browne S. Incidence and clinical correlates of aggression and violence at presentation in patients with first episode psychosis. Schizophrenia Research 72(2-3): 161-168, 2005. (22 refs.)

This study aimed to identify the incidence and clinical correlates of aggression and violence in first episode psychosis. We prospectively recruited subjects with a first episode of DSM-psychosis presenting from a geographically defined catchment area to a secondary referral psychiatric service over a four-year period (n = 157). We used the Modified Overt Aggression Scale to retrospectively assess aggression (a hostile or destructive mental attitude, including verbal aggression, physical aggression and/or violence) and violence (the exercise of physical force), blind to diagnosis. One in three patients with psychosis was aggressive at the time of presentation. One patient in 14 engaged in violence that caused, or was likely to cause, injury to other people. Aggression was independently associated with drug misuse (odds ratio (OR) 2.80, 95% confidence interval 1.12-6.99) and involuntary admission status (OR = 3.62, 95% CI 1.45-9.01). Violence in the week prior to presentation was associated with drug misuse (OR = 2.75, CI 1.04 - 7.24) and involuntary admission status (OR = 3.21 CI 1.21-8.50). Violence in the week following presentation was associated with poor insight (OR 2.97, CI 1.03-8.56) and pre-contact violence (OR 3.82. CI 1.34-10.88). In patients with schizophrenia, violence in the week following presentation was associated with drug misuse (OR = 7.81, CI 1.33-45.95) and high psychopathology scores (OR = 20.59. CI 1.66-254.96). Overall, despite a high rate of verbal aggression, physical violence towards other people is uncommon in individuals presenting with first episode psychosis.

Folsom DP; Hawthorne W; Lindamer L; Gilmer T; Bailey A; Golshan S et al. Prevalence and risk factors for homelessness and utilization of mental health services among 10,340 patients with serious mental illness in a large public mental health system. American Journal of Psychiatry 162(2): 370-376, 2005. (42 refs.)

Objective: The authors examined the prevalence of and risk factors for homelessness among all patients treated for serious mental illnesses in a large public mental health system in a 1-year period. The use of public mental health services among homeless persons was also examined. Method: The study included 10,340 persons treated for schizophrenia, bipolar disorder, or major depression in the San Diego County Adult Mental Health Services over a 1-year period (1999 - 2000). Analytic methods that adjusted for potentially confounding variables were used. Multivariate logistic regression analyses were used to calculate odds ratios for the factors associated with homelessness, including age, gender, ethnicity, substance use disorder, Medicaid insurance, psychiatric diagnosis, and level of functioning. Similarly, odds ratios were computed for utilization of mental health services by homeless versus not-homeless patients. Results: The prevalence of homelessness was 15%. Homelessness was associated with male gender, African American ethnicity, presence of a substance use disorder, lack of Medicaid, a diagnosis of schizophrenia or bipolar disorder, and poorer functioning. Latinos and Asian Americans were less likely to be homeless. Homeless patients used more inpatient and emergency-type services and fewer outpatient-type services. Conclusions: Homelessness is a serious problem among patients with severe mental illness. Interventions focusing on potentially modifiable factors such as substance use disorders and a lack of Medicaid need to be studied in this population.

Green AI. Schizophrenia and comorbid substance use disorder: Effects of antipsychotics. Journal of Clinical Psychiatry 66(Supplement 6): 21-26, 2005. (55 refs.)

The rate of comorbid substance use disorder in patients with schizophrenia is 3 times higher than that in the general population. Men with schizophrenia appear to be particularly vulnerable to substance use disorders. Substances commonly abused in patients with schizophrenia include alcohol, cannabis, and cocaine. Although the basis of comorbidity is unclear, a number of theories have been proposed, including the possibility of a deficiency in the dopamine-mediated mesocorticolimbic brain reward circuit. Data suggest that substance abuse may complicate and worsen the course of schizophrenia. Early intervention with appropriate pharmacotherapy may prove beneficial and potentially improve the long-term course of the disorder. Conventional antipsychotics have not been overly useful in this patient population, but some atypical antipsychotics have been shown to reduce the use of alcohol, cannabis, cocaine, and tobacco in patients with schizophrenia. Further research is required, but early evidence suggests that at least some atypical antipsychotics may prove to be therapeutically effective in the treatment of patients with schizophrenia and comorbid substance use disorder.

Green AI. Treatment of schizophrenia and comorbid substance abuse: Pharmacologic approaches. Journal of Clinical Psychiatry 67(Supplement 7): 31-35, 2006. (68 refs.)

Co-occurring substance use disorder is common among patients with schizophrenia, and its presence greatly worsens the course of schizophrenia. A number of theories have been introduced to explain the increased rate of substance use disorder in these patients. These theories include the notion that substance use could trigger psychotic symptoms in vulnerable individuals and the idea that the substances are used to self-medicate symptoms of schizophrenia. Our group and others have advanced a neurobiological hypothesis to explain this comorbidity-that a mesocorticolimbic brain reward circuit underlies the substance use disorder in patients with schizophrenia. Treatment of substance use disorder in these patients is best done with integrated treatment programs that combine psychosocial interventions with pharmacotberapy. Recent data suggest that the atypical antipsychotic clozapine and perhaps other atypical agents may lessen substance use in patients with schizophrenia. My colleagues and I have proposed that clozapine's effect in these patients may be related to its ability to decrease the brain reward circuit dysfunction. Research is continuing on the use of atypical antipsychotics in patients with schizophrenia and comorbid substance abuse. The adjunctive use of naltrexone or other agents also may be helpful. Further research on the optimal pharmacologic approach to patients with dual diagnosis is needed.

Haw C; Hawton K; Sutton L; Sinclair J; Deeks J. Schizophrenia and deliberate self-harm: A systematic review of risk factors. (review). Suicide and Life-threatening Behavior 35(1): 50-62, 2005. (42 refs.)

Deliberate self-harm (DSH) is a strong predictor of suicide in schizophrenia. The aim of this review was to identify risk factors for DSH in schizophrenia. This systematic review of the international literature examined cohort and case-control studies of patients with schizophrenia or related diagnoses that reported DSH as an outcome. Studies were identified by searching electronic databases and reference lists, and by consulting international experts. Fourteen studies met the eligibility criteria. Of the 29 variables examined by two or more studies, five (past or recent suicidal ideation, previous DSH, past depressive episode, drug abuse or dependence, and higher mean number of psychiatric admissions) were associated with an increased risk of DSH, and one (unemployment) was associated with a reduced risk. Schizophrenic patients with these risk factors need careful follow-up and monitoring, with treatment of any associated comorbid depression or drug abuse. Large, prospective studies of DSH in schizophrenia are needed to further define risk factors and to build on the findings of this review.

Huckans MS; Blackwell AD; Harms TA; Indest D; Hauser P. Integrated hepatitis C virus treatment: Addressing comorbid substance use disorders and HIV infection. AIDS 19(Supplement 3): S106-S115, 2005. (26 refs.)

Objectives: To examine hepatitis C virus (HCV) and HIV testing patterns within the Northwest Veterans Integrated Service Network (VISN 20). Methods: Using a comprehensive VISN 20 database, we retrospectively reviewed medical records of 293 445 veterans. Results: 32.8% of patients were tested for HCV, 5.5% were tested for HIV, and 4.3% were co-tested. Of those tested, 12.3% were HCV positive, 5.4% were HIV positive, and 1.6% were co-infected. 79.1 % of HIV-positive patients were tested for HCV, 29.2% of whom tested positive. 34.8% of HCV-positive patients were tested for HIV, 4.9% of whom tested positive. Of those tested, HCV-positive patients were significantly more likely than HCV-negative patients to test positive for HIV; HIV-positive patients were no more likely to test positive for HCV than HIV-negative patients. HIV-positive patients with substance use disorders (SUD) were significantly more likely to test HCV positive than those without. Within the total sample, veterans with SUD were significantly more likely to be tested for both diseases and to test positive for HCV but not HIV. After controlling for other categories of SUD, veterans with a history of cocaine abuse compared with those without were at an increased risk of HIV infection and co-infection. Conclusion: 79.1 % of HIV-positive but only 34.8% of HCV-positive veterans were cotested, suggesting barriers to HIV testing may exist in VISN 20. Results also indicate that HCV-positive patients are at increased risk for HIV infection and that HIV-positive patients with SUD are at increased risk of HCV infection; routine co-testing for these patients is therefore warranted. Given significant co-infection rates, HCV and HIV screening and testing should be increasingly integrated. Increased infection rates among patients with SUD also warrant integration of HCV and HIV screening and testing into mental health and addiction programmes.

Huguelet P; Morand-Collomb S. Effect of topiramate augmentation on two patients suffering from schizophrenia or bipolar disorder with comorbid alcohol abuse. Pharmacological Research 52(5): 392-394, 2005. (20 refs.)

Two cases of patients with a severe comorbidity of alcohol abuse treated with topiramate are reported. The first case is a 52-year-old patient who has been suffering from schizophrenia for many years. Topiramate prescription was associated with a discontinuation of his chronic, refractory alcohol consumption. The second case is a 41-year-old patient with bipolar disorder that mainly manifests itself through manic episodes. Topiramate treatment allowed him to decrease his alcohol intake to an acceptable level. Consequently, his bipolar symptoms also improved, without the appearance of any side effects. Thus, topiramate may improve alcohol intake among patients with schizophrenia or bipolar disorder. Certain studies have shown the efficacy of topiramate in alcoholic patients without such associated disorders, but further research is needed for this special population.

Junginger J; Claypoole K; Laygo R; Crisanti A. Effects of serious mental illness and substance abuse on criminal offenses. Psychiatric Services 57(6): 879-882, 2006. (11 refs.)

Objective: Some believe serious mental illness has been "criminalized." Effects of serious mental illness and substance abuse on criminal offenses were studied for 113 postbooking jail diversion participants and their nondiverted counterparts. Methods: Raters read participants' and police report descriptions of criminal offenses and participants' explanations for them. Using 5-point scales, raters independently estimated whether an offense resulted directly or indirectly from serious mental illness or substance abuse. Results: Serious mental illness and substance abuse had little effect on offenses. However, substance abuse led to a sizable minority of offenses and was more likely than mental illness to cause an offense. Conclusions: Unless factors unique to serious mental illness can be specifically associated with behavior leading to incarceration, the criminalization hypothesis should be reconsidered in favor of more powerful risk factors for crime that are widespread in social settings of persons with serious mental illness.

Kalyoncu A; Mirsal H; Pektas O; Unsalan N; Tan D; Beyazyurek M. Use of lamotrigine to augment clozapine in patients with resistant schizophrenia and comorbid alcohol dependence: A potent anti-craving effect? Journal of Psychopharmacology 19(3): 301-305, 2005. (25 refs.)

Comorbid alcohol dependence is common in patients with schizophrenia and is associated with a variety of serious adverse consequences. Although case reports exist concerning the positive impact of lamotrigine addition on clozapine treatment in resistant schizophrenia, a review of the literature fails to document any evidence regarding a combination of the two in the treatment of patients with schizophrenia and comorbid alcohol dependence. In the present study, we present three cases in which patients with resistant schizophrenia and comorbid alcohol use disorder were given lamotrigine to augment clozapine. Our findings suggest that clozapine plus lamotrigine may be helpful in reducing alcohol consumption and craving among patients with schizophrenia and comorbid alcohol dependence.

Kedzior KK; Martin-Iverson MT. Chronic cannabis use is associated with attention-modulated reduction in prepulse inhibition of the startle reflex in healthy humans. Journal of Psychopharmacology 20(4): 471-484, 2006. (86 refs.)

Regardless of a wide research interest the nature of a relationship between cannabis use and schizophrenia is controversial. One of the physiological abnormalities in schizophrenia is attention-modulated deficit in prepulse inhibition (PPI), which is a normal reduction in the startle reflex magnitude when a non-startling stimulus (prepulse) precedes the startling stimulus (pulse). This experiment was designed to determine whether or not otherwise healthy people using cannabis would exhibit attention-modulated deficit in PPI. The startle reflex was recorded in carefully screened healthy humans attending to and ignoring auditory pulse and prepulse stimuli separated by short (20-200 ms) and tong prepulse intervals (1600 ms). In contrast to 12 non-using controls, cannabis use in 16 healthy humans was associated with significant reduction in %PPI white attending to auditory stimuli, but not while ignoring them. The PPI was correlated with the duration of cannabis use but not with the concentration of cannabinoid metabolites in urine and the recency of cannabis use in the preceding 24 hours. Cannabis use was not associated with changes in prepulse facititation of startle reflex magnitude (%PPF) at tong prepulse intervals, prepulse facilitation of startle reflex latency and startle reflex magnitude in the absence of prepulses. These results suggest that chronic, but not acute, use of cannabis is associated with schizophrenia-like disruption in PPI in healthy controls. Such reduction in PPI is attention-dependent and does not reflect a global deficit in sensorimotor gating in cannabis users.

Korkeila J; Heikkila J; Hansson L; Sorgaard K; Vahlberg T; Karlsson H. Structure of needs among persons with schizophrenia. Social Psychiatry and Psychiatric Epidemiology 40(3): 233-239, 2005. (22 refs.)

Background: The importance of needs assessment for service development has been widely recognised. Several studies have focused on the associations between ratings of needs by patients and staff and have found clear differences, especially concerning the unmet needs. Methods: The present study is part of a Nordic Multicentre study that investigates the life and care of outpatients with a schizophrenia group illness in all the Nordic countries. The aim of this paper is to study the patterns of needs as identified by patients and staff according to the Camberwell Assessment of Needs (CAN). Quality of life, level of functioning, and psychiatric symptoms were assessed. Results: The sample includes 300 patients, 194 (65%) men and 106 (35%) women. The factor analysis identified five factors for patients and four factors for staff in the questionnaire on ratings of needs. In four of the five patient-related factors a meaningful interpretation was possible, and the factors were named skills, illness, coping, and substance abuse. The staff-related factors were named skills, impairment, symptom, and substance abuse. There were significant associations between the sum scores constructed from the factors and measures of functioning level and symptoms. Conclusions: It seems that the sum factor reflecting secondary needs was the most important of the identified factors among both patient and staff ratings. The item-by-item comparisons in previous studies have emphasised differences between patient and staff ratings, but our analysis of the structure of needs also found similarities in the structures and in the associations between the identified sum scores and measures of symptoms, functioning level, and quality of life.

Kumari V; Postma P. Nicotine use in schizophrenia: The self-medication hypothesis. (review). Neuroscience and Biobehavioral Reviews 29(6 (Special Issue)): 1021+, 2005. (183 refs.)

The behavioural and cognitive effects of nicotine in schizophrenia have received much interest in recent years. The rate of smoking in patients with schizophrenia is estimated to be two- to four-fold the rate seen in the general population. Furthermore such patients favour stronger cigarettes and may also extract more nicotine from their cigarettes than other smokers. The question has been raised whether the widespread smoking behaviour seen in this patient group is in fact a manifestation of a common underlying physiology, and that these patients smoke in an attempt to self-medicate. We present an overview of the explanations for elevated rates of smoking in schizophrenia, with particular emphasis on the theories relating this behaviour to sensory gating and cognitive deficits in this disorder that have been viewed as major support for the self-medication hypotheses.

Kumra S; Thaden E; DeThomas C; Kranzler H. Correlates of substance abuse in adolescents with treatment-refractory schizophrenia and schizoaffective disorder. (letter). Schizophrenia Resarch 73(2/3): 369-371, 2005. (9 refs.)

Leff HS; Wieman DA; McFarland BH; Morrissey JP; Rothbard A; Shern DL et al. Assessment of Medicaid managed behavioral health care for persons with serious mental illness. Psychiatric Services 56(10): 1245-1253, 2005. (48 refs.)

Objectives: This five-site study compared Medicaid managed behavioral health programs and fee-for-service programs on use and quality of services, satisfaction, and symptoms and functioning of adults with serious mental illness. Methods: Adults with serious mental illness in managed care programs (N=958) and fee-for-service programs (N=1,011) in five states were interviewed after the implementation of managed care and six months later. After a multiple regression to standardize the groups for case mix differences, a meta-analysis using a random-effects model was conducted, and bioequivalence methods were used to determine whether differences were significant for clinical or policy purposes. Results: A significantly smaller proportion of the managed care group received inpatient care (5.7 percent compared with 11.5 percent). The managed care group received significantly more hours of primary care (4.9 compared with 4.5 hours) and was significantly less healthy. However, none of these differences exceed the bioequivalence criterion of 5 percent. Managed care and fee for service were "not different but not equivalent" on 20 of 34 dependent variables. Cochrane's Q statistic, which measured intersite consistency, was significant for 20 variables. Conclusions: Managed care and fee-for-service Medicaid programs did not differ on most measures; however, a lack of sufficient power was evident for many measures. Full endorsement of managed care for vulnerable populations will require further research that assumes low penetration rates and intersite variability.

McGovern MP; Wrisley BR; Drake RE. Relapse of substance use disorder and its prevention among persons with co-occurring disorders. Psychiatric Services 56(10): 1270-1273, 2005. (42 refs.)

This article summarizes the scientific literature on the relapse process, describes the basic principles of relapse prevention treatment, highlights the major empirical studies, and offers suggestions for future research and application, especially in terms of ongoing care for persons with co-occurring disorders. Relapse prevention treatments have a well-established efficacy and effectiveness for persons with substance use disorders. Key ingredients include reducing exposure to substances, fostering motivation for abstinence, self-monitoring, recognizing and coping with cravings and negative affect, identifying thought processes with relapse potential, and deploying, if necessary, a crisis plan. Relapse prevention approaches may be best suited for persons in the action of maintenance stages of treatment or recovery. Further research is needed to examine relapse prevention therapies as a key component to continuing care for persons with co-occurring substance use and psychiatric disorders.

McGovern MP; Xie HY; Segal SR; Siembab L; Drake RE. Addiction treatment services and co-occurring disorders: Prevalence estimates, treatment practices, and barriers. Journal of Substance Abuse Treatment 31(3): 267-275, 2006. (33 refs.)

As the model for treating co-occurring disorders in addiction treatment settings becomes articulated, service systems need data on prevalence, current practice, and barriers to the implementation of evidence-based practices. A self-report survey was administered to 45 3 addiction treatment providers (43 agency directors, 110 clinical supervisors, and 300 clinicians) from a single state system of care. Data on prevalence estimates, treatment practices, and barriers to implementing services for co-occurring disorders were obtained. The three groups estimated that several co-occurring disorders were extremely common: mood disorders (40%-42%), anxiety disorders (24%-27%), posttraumatic stress disorder (24%-27%), severe mental illnesses (16%-21%), antisocial personality disorder (18%-20%), and borderline personality disorder (17%-18%). Practice patterns for patients with these co-occurring disorders differed widely, from referral to mental health programs to provision of integrated treatment. Common barriers to providing services to persons with co-occurring disorders were lack of psychiatric personnel and resources. Comprehensive surveys of an addiction treatment service system can rapidly and economically produce estimates of prevalence, current practices, and barriers to evidence-based practices. This objective information is critical for systems intending to enhance services to persons with co-occurring disorders.

McHugo GJ; Drake RE; Brunette MF; Xie HY; Essock SM; Green AI. Enhancing validity in co-occurring disorders treatment research. Schizophrenia Bulletin 32(4): 655-665, 2006. (65 refs.)

Despite the high prevalence of co-occurring mental health and substance-use disorders, there has been a relative lack of treatment research with this population, and the existing research often has limited validity. This article explores some of the barriers to the conduct of research on promising interventions for substance-abuse treatment for people with co-occurring disorders, using the concepts of external and ecological validity to make recommendations for future investigation. The central recommendation is to move rapidly from efficacy studies to more credible and valid effectiveness studies, in order to facilitate the adoption of evidence-based interventions in routine practice settings.

Public Domain

Meade CS; Sikkema KJ. HIV risk behavior among adults with severe mental illness: A systematic review. (review). Clinical Psychology Review 25(4): 433-457, 2005. (128 refs.)

Adults with severe mental illness (SMI) have been disproportionately affected by the HIV/AIDS epidemic. This systematic review of the empirical literature on SMI documents the prevalence and correlates of HIV risk behaviors, discusses clinical implications for HIV prevention, and recommends directions for future research. Prevalence rates of HIV risk behaviors were estimated using weighted means, and findings on correlates were synthesized. Across reviewed studies (N=52), the majority of adults with SMI were sexually active, and many engaged in risk behaviors associated with HIV transmission (e.g., unprotected intercourse, multiple partners, injection drug use). HIV risk behaviors were correlated with factors from the following domains: psychiatric illness, substance use, childhood abuse, cognitive-behavioral factors, and social relationships. A proposed model illustrates the multiple pathways linking these domains to HIV risk behavior. Further research using improved methodologies (e.g., longitudinal designs, standardized measures, multivariate analyses) is needed to examine the broader social context in which HIV risk behavior occurs and identify underlying processes. HIV prevention efforts targeting adults with SMI must occur on multiple levels (e.g., individual, group, community, structural/policy), address several domains of influence (e.g., psychiatric illness, trauma history, social relationships), and be integrated into existing services (e.g., psychotherapy, substance abuse treatment, housing programs).

Mirkin B; Earleywine M. The cannabis and psychosis connection questioned: A comment on Fergusson et al. 2005. (letter). Addiction 100(5): 714, 2005. (4 refs.)

Montross LP; Barrio C; Yamada AM; Lindamer L; Golshan S; Garcia P et al. Tri-ethnic variations of co-morbid substance and alcohol use disorders in schizophrenia. Schizophrenia Research 79(2-3): 297-305, 2005. (28 refs.)

Objectives: This study examined the differential prevalence of substance and alcohol use disorders among European Americans, African Americans, and Latinos with schizophrenia (n = 6424) who received public mental health services in San Diego County during fiscal year 2002-2003. Methods: Data were obtained from the public mental health database used by the San Diego County Mental Health System. Chi-Square analyses and stepwise logistic regression analyses were used to examine differences regarding the prevalence of substance and alcohol use among clients with schizophrenia and schizoaffective disorder, and to analyze the sociodemographic variables associated with this co-morbidity. Results: Significant differences in the prevalence of diagnosed co-morbidity were found across the ethnic groups. Rates of comorbid diagnosis among African Americans (25%) were significantly higher than those among European Americans (22%) and Latinos (19%). Logistic regression results revealed ethnicity was a significant predictor of co-morbid substance and alcohol use, as was being homeless and male. Among Latinos, language preference was also a significant predictor. Latinos who denoted English as their primary language were 1.7 times more likely to be diagnosed with co-morbid substance or alcohol use disorders than Latinos who denoted Spanish. Conclusions: Among people with schizophrenia, there were significant differences in prevalence rates and predictors of diagnosed co-morbid substance and alcohol use disorders. Future research is needed to examine the relationship among language preference, level of acculturation, and subsequent diagnosing barriers for Latinos. Among African Americans, the reasons behind increased co-morbidity rates need to be examined, and homelessness should be carefully addressed among all three ethnic groups.

Morrissey JP; Jackson EW; Ellis AR; Amaro H; Brown VB; Najavits LM. Twelve-month outcomes of trauma-informed interventions for women with co-occurring disorders. Psychiatric Services 56(10): 1213-1222, 2005. (40 refs.)

Objective: Women with co-occurring mental health and substance use disorders frequently have a history of interpersonal violence, and past research has suggested that they are not served effectively by the current service system. The goal of the Women, Co-occurring Disorders, and Violence Study was to develop and test the effectiveness of new service approaches specifically designed for these women. Methods: A quasi-experimental treatment outcome study was conducted from 2001 to 2003 at nine sites. Although intervention specifics such as treatment length and modality varied across sites, each site used a comprehensive, integrated, trauma-informed, and consumer-involved approach to treatment. Substance use problem severity, mental health symptoms, and trauma symptoms were measured at baseline, and follow-up data were analyzed with prospective meta-analysis and hierarchical linear modeling. Results: A total of 2,026 women had data at the 12-month follow-up: 1,018 in the intervention group and 1,008 in the usual-care group. For substance use outcomes, no effect was found. The meta-analysis demonstrated small but statistically significant overall improvement in women's trauma and mental health symptoms in the intervention relative to the usual-care comparison condition. Analysis of key program elements demonstrated that integrating substance abuse, mental health, and trauma-related issues into counseling yielded greater improvement, whereas the delivery of numerous core services yielded less improvement relative to the comparison group. A few person-level characteristics were associated with increases or decreases in the intervention effect. These neither moderated nor supplanted the effects of integrated counseling. Conclusions: Outcomes for women with co-occurring disorders and a history of violence and trauma may improve with integrated treatment.

Mueser KT; Crocker AG; Frisman LB; Drake RE; Covell NH; Essock SM. Conduct disorder and antisocial personality disorder in persons with severe psychiatric and substance use disorders. Schizophrenia Bulletin 32(4): 626-636, 2006. (77 refs.)

Conduct disorder (CD) and antisocial personality disorder (ASPD) are established risk factors for substance use disorders in both the general population and among persons with schizophrenia and other severe mental illnesses. Among clients with substance use disorders in the general population, CD and ASPD are associated with more severe problems and criminal justice involvement, but little research has examined their correlates in clients with dual disorders. To address this question, we compared the demographic, substance abuse, clinical, homelessness, sexual risk, and criminal justice characteristics of 178 dual disorder clients living in 2 urban areas between 4 groups: No CD/ASPD, CD Only, Adult ASPD Only, and Full ASPD. Clients in the Adult ASPD only group tended to have the most severe drug abuse severity, the most extensive homelessness, and the most lifetime sexual partners, followed by the Full ASPD group, compared with the other 2 groups. However, clients with Full ASPD had the most criminal justice involvement, especially with respect to violent charges and convictions. The results suggest that a late-onset ASPD subtype may develop in clients with severe mental illness secondary to substance abuse, but that much criminal behavior in clients with dual disorders may be due to the early onset of the full ASPD syndrome in this population and not the effects of substance use disorders.

Public Domain

Nyamathi AM; Christiani A; Windokun F; Jones T; Strehlow A; Shoptaw S. Hepatitis C virus infection, substance use and mental illness among homeless youth: A review. AIDS 19(Supplement 3): S34-S40, 2005. (51 refs.)

Objectives: Homeless youth are at a high risk of substance abuse, mental illness and blood-borne infections, such as hepatitis C. In this paper, we review the implications of these conditions, discuss the unique challenges faced by homeless youth, and explore potential strategies for harm reduction and intervention in this vulnerable population. Results: Interventions that combine youth-centered, service-based care, street out-reach, case management, and motivational interviewing with integrated health services such as hepatitis A/B vaccination, and mental health and substance abuse programmes, are presented as innovative approaches to address the healthcare needs of homeless youth. Conclusion: Recommendations for age-appropriate interventions and further research are made.

Potvin S; Stip E; Lipp O; Elie R; Mancini-Marie A; Demers MF et al. Quetiapine in patients with comorbid schizophrenia-spectrum and substance use disorders: An open-label trial. Current Medical Research and Opinion 22(7): 1277-1285, 2006. (40 refs.)

Background: Preliminary evidence suggests that clozapine relieves the craving for psychoactive substances in schizophrenia patients. Quetiapine shares crucial pharmacological properties with clozapine. Promising results have been described with quetiapine therapy in patients with psychosis and substance use disorder. Methods: Based on Diagnostic and Statistical Manual of Mental Disorders-fourth edition (DSM-IV) criteria, patients were diagnosed with comorbid schizophrenia-spectrum and substance use disorders. Patients were switched to quetiapine for a 12-week open-label trial. Craving, quantities used, days of consumption, and severity of substance abuse were assessed every 3 weeks. Alcohol and Drug Use Scales were administered on baseline and end-point. Psychiatric symptoms, depressive symptoms, extrapyramidal symptoms, and cognition were also assessed at baseline, week 6 and week 12. Results: Twenty-four schizophrenia-spectrum patients were included in the last observation carried forward (LOCF) analyses, responding to one or more of the following substance use disorders: cannabis ( 15 patients), alcohol ( 10 patients), and other psychoactive substances ( nine patients). Overall, severity of substance abuse improved during the study. Less weekly days were spent on drugs of abuse. A decrease in the weekly Canadian dollars spent on psychoactive substances was also observed. Cognition, psychiatric, depressive, and extrapyramidal symptoms also significantly improved ( p < 0.05). Conclusions: In this open-label, uncontrolled trial, significant improvements were noted in substance abuse, psychiatric symptoms, extrapyramidal symptoms, and cognition during quetiapine therapy. The study suffered from three main limitations: ( 1) the open-label design of the study; ( 2) the patients' poor compliance; and ( 3) the small sample size involved. Controlled studies on the use of quetiapine in dual diagnosis schizophrenia are warranted to confirm that the effects are drug-related.

Rich AR; Clark C. Gender differences in response to homelessness services. Evaluation and Program Planning 28(1): 69-81, 2005. (62 refs.)

This study examines the importance of considering gender in evaluating the effectiveness of homelessness service interventions among solitary adults with severe mental illnesses. The participants received services in one of two types of evidenced-based homelessness intervention programs: a comprehensive housing program or a specialized case management program. Using a quasi-experimental research design with non-random assignment to conditions, we examined changes in housing status, mental health, substance use, quality of life and physical health from baseline to 6 and 12 months afterward. One hundred and fifty-two participants completed the baseline interview and 108 were available for at least one of the follow-up interviews. The results indicated that males had significantly greater reductions in homelessness in the comprehensive housing program than in the specialized case management program. whereas females showed a more complex pattern. Women in both programs showed significant reductions in homelessness, but females in the specialized case management program achieved greater stable housing time because women in the comprehensive housing program were more likely to have their time, in stable housing reduced by stays in psychiatric hospitals. We conclude that variables such as gender that have been shown to influence the etiology, nature, and course of homelessness should also be considered in evaluating the effectiveness of homeless services interventions.

Rollins AL; O' Neill SJ; Davis KE; Devitt TS. Substance abuse relapse and factors associated with relapse in an inner-city sample of patients with dual diagnoses. Psychiatric Services 56(10): 1274-1281, 2005. (39 refs.)

Objective: This study documented rates of substance abuse relapse and explored factors associated with sustained remission among consumers with severe mental illness in a large, urban clinical sample. Methods: Existing clinical records of consumers with severe mental illness and co-occurring substance use disorders who had achieved remission and who were interviewed at two or more subsequent follow-up points (12 months after remission) were reviewed. Consumers who relapsed within 12 months after remission were compared with those who maintained remission on demographic, clinical, and functional indicators. Results: Of the 133 consumers who achieved remission, 91 (68 percent) had maintained remission at six-month follow-up, and 69 (52 percent) had maintained remission at 12-month follow-up. The strongest factors associated with maintenance of remission at 12 months were older age and living in Thresholds residential programs. Multivariate analysis showed that consumers who were older, held jobs, and lived in Thresholds residential programs at initial remission had a higher likelihood of maintaining remission at 12 months. To explore the potential impact of program dropout on the results, supplemental analyses using a third group without 12-month follow-up data were conducted. These analyses indicated that program dropouts were younger and less likely to live in Thresholds residential programs at initial remission. Conclusions: Age, therapeutic residential programming, and, to a lesser degree, employment appear to be potential factors to consider in the development of relapse prevention models.

Rosenberg SD; Drake RE; Brunette MF; Wolford GL; Marsh BJ. Hepatitis C virus and HIV co-infection in people with severe mental illness and substance use disorders. AIDS 19(Supplement 3): S26-S33, 2005. (68 refs.)

Objectives: The 5-7% of adults in the United States with severe mental illness (SMI), especially the 50% who are 'dually diagnosed' with co-occurring substance use disorders (SUD), are at an elevated risk of HIV and hepatitis C virus (HCV). However, little is known about HIV/HCV co-infection in this population. This paper examines the prevalence and correlates of HIV, hepatitis C, and HIV/HCV co-infection in a large, multisite sample of SMI clients. Design: We conducted a re-analysis of data on prevalence and correlates of blood-borne infections in a multisite sample of SMI clients. Methods: In 1997-1998, 755 SMI clients were tested for HIV, hepatitis B virus and HCV, and assessed for demographic, illness-related and other behavioral risk factors for blood-borne infections. The prevalence and correlates of co-infection were examined, as well as the knowledge, attitudes and risk behaviors of individuals with HCV mono-infection. Results: Of the 755 participants, 623 (82.5%) were negative for both HIV and HCV, 23 (3.0%) were positive for HIV, 109 (14.4%) were positive for HCV, and 13 (1.7%) were co-infected with HIV and HCV. Overall, 2.5% of dually diagnosed participants were co-infected, whereas only 0.6% of SMI participants without a comorbid SUD diagnosis were co-infected. Co-infection was associated with psychiatric illness severity, ongoing drug abuse, poverty, homelessness, incarceration, urban residence and minority status. HCV-mono-infected clients continued to engage in high levels of risk behavior for HIV. Conclusion: In addition to efforts to identify and treat SMI patients with HIV/HCV co-infection, HCV-mono-infected clients should be targeted for prevention interventions.

Sacco KA; Termine A; Seyal A; Dudas MM; Vessicchio JC; Krishnan-Sarin S et al. Effects of cigarette smoking on spatial working memory and attentional deficits in schizophrenia: Involvement of nicotinic receptor mechanisms. Archives of General Psychiatry 62(6): 649-659, 2005. (81 refs.)

Background: Cigarette smoking rates in schizophrenia are higher than in the general population. Objectives: To determine whether cigarette smoking modifies cognitive deficits in schizophrenia and to establish the role of nicotinic acetylcholine receptors (nAChRs) in mediating cigarette smoking-related cognitive enhancement. Design: Neuropsychological assessments were performed at smoking baseline, after overnight abstinence, and after smoking reinstatement across 3 separate test weeks during which subjects were pretreated in a counterbalanced manner with the nonselective nAChR antagonist mecamylamine hydrochloride (0, 5, or 10 mg/d). Participants: Twenty-five smokers with schizophrenia and 25 control smokers. Setting: Outpatient mental health center. Main Outcome Measures: Visuospatial working memory (VSWM) and Continuous Performance Test (CPT) scores. Results: In smokers with schizophrenia and control smokers, overnight abstinence led to undetectable plasma nicotine levels and an increase in tobacco craving. While abstinence reduced CPT hit rate in both groups, VSWM was only impaired in smokers with schizophrenia. Smoking reinstatement reversed abstinence-induced cognitive impairment. Enhancement of VSWM and CPT performance by smoking reinstatement in smokers with schizophrenia, but not the subjective effects of smoking, was blocked by mecamylamine treatment. Conclusions: Cigarette smoking may selectively enhance VSWM and attentional deficits in smokers with schizophrenia, which may depend on nAChR stimulation. These findings may have implications for understanding the high rates of smoking in schizophrenia and for developing pharmacotherapies for cognitive deficits and nicotine dependence in schizophrenia.

Sigmon SC; Higgins ST. Voucher-based contingent reinforcement of marijuana abstinence among individuals with serious mental illness. Journal of Substance Abuse Treatment 30(4): 291-295, 2006. (13 refs.)

Previous studies by our group have used money given contingent on abstinence to reduce drug use by individuals with schizophrenia. In this study, we examined the sensitivity of marijuana use by individuals with serious mental illness to voucher-based contingent reinforcement. which represents the first study to date investigating the efficacy of voucher incentives with this population. This within subject reversal design consisted of three conditions: 4-week baseline, 12-week voucher intervention, and 4-week baseline. During baseline periods. subjects received US$10 vouchers per urine specimen, independent Of urinalysis results. During voucher intervention, only specimens testing negative for marijuana earned vouchers, with total possible earnings of US$930. Seven adults with schizophrenia or other serious mental illnesses participated in the study. The percentage of marijuana-negative specimens was significantly greater during voucher intervention than during baseline periods. These results provide evidence that marijuana use among individuals with serious mental illness is sensitive to voucher-based incentives and further support the potential feasibility of using voucher-based contingency management to reduce substance abuse in this challenging population.

Steinberg ML; Williams JM; Steinberg HR; Krejci JA; Ziedonis DM. Applicability of the Fagerstrom Test for Nicotine Dependence in smokers with schizophrenia. Addictive Behaviors 30(1): 49-59, 2005. (34 refs.)

Up to 90% of individuals with schizophrenia smoke cigarettes, and many show signs of heavy dependence. Although the severity of nicotine dependence is often measured by the six-item Fagerstr�m Test for Nicotine Dependence (FTND), this measure, in its current form, may not be as appropriate in this population-or in others who's smoking is regulated by others-as in the general population due to differences in smoking patterns, living arrangements, and daily routines. These factors may produce an underestimate of nicotine dependence, which may have clinical implications for successful medical detoxification if the FTND scores are used to guide the dosage of nicotine replacement medication. Data indicate poor internal consistency reliability (=.4581) and a factor pattern lacking simple structure (i.e., two nonmeaningful factors/components with substantial cross loadings) when administered to smokers with schizophrenia. Specific examples of problematic items and how these may contribute to an underestimate of tobacco dependence severity are discussed, as well as ways to modify the FTND to be more appropriate for this population.

Stohler R; Rossler W, eds. Dual Diagnosis: The Evolving Conceptual Framework. Basal: S. Karger, 2005. (Chapter refs.)

Dual diagnoses of substance abuse and mental disorders (mostly schizophrenia, affective, anxiety, personality, or attention deficit/hyperactivity disorder) are among the most prevalent mental disorders worldwide. They place an enormous burden on individuals and society. In June 2003 the Psychiatric University Hospital of Zurich, Switzerland, organized an international symposium to celebrate the tenth anniversary of its dual diagnosis ward, the only remaining such facility in the country. The conference focused on etiology, diagnosis, and treatment of dual diagnosis. The volume has nine chapters with 18 contributors. These chapters consider theories of etiology; the genetic basis of substance use and abuse; the routes connecting personality disorders and substance use disorders; historical and conceptual approaches; diagnostic issues; neurocognitive impairments; and modified therapeutic communities for co-occurring disorders, as well as chapters with an emphasis on comorbidities dealing with alcohol disorders, Anxiety Disorders, and Attention Deficit/Hyperactivity Disorders.

Stuyt EB; Sajbel TA; Allen MH. Differing effects of antipsychotic medications on substance abuse treatment patients with co-occurring psychotic and substance abuse disorders. American Journal on Addictions 15(2): 166-173, 2006. (33 refs.)

This retrospective study of patients treated in a ninety-day, inpatient, dual-diagnosis treatment program examined antipsychotic effectiveness in this population using length of stay in treatment and successful program completion as outcome measures. All patients with co-occurring substance dependence and schizophrenia or schizoaffective disorder treated with olanzapine, risperidone, ziprasidone, and typical depot neuroleptics from January 2001 to December 2003 (N = 55) are the subjects of this study. Patients stayed longer in treatment when taking risperidone ( 82 +/- 19 days) or ziprasidone ( 74 +/- 21 days) compared with olanzapine ( 44 +/- 30 days) or typicals ( 47 +/- 36 days). Eighty-eight percent of risperidone patients and 64% of ziprasidone patients successfully completed the program, while only 33% of olanzapine patients and 40% of patients on typicals successfully completed the program. Risperidone and ziprasidone were associated with significantly better program performance than olanzapine or depot typicals in this population. Possible reasons for this difference are discussed.

Swartz JA; Lurigio AJ. Detecting serious mental illlness among substance abusers: Use of the K6 Screening Scale. IN: Hilarski C, ed. Addiction, Assessment, and Treatment with Adolescents, Adults, and Families. New York: Haworth Social Work Practice Press, 2005. pp. 113-136. (45 refs.)

Serious mental illnesses (SMIs) commonly co-occur with substanc use disorders and, if undetected and untreated, aversely affect their clinical course. This paper describes the use and scoring of the K6 scale, a brief and valid screening tool for serious mental disorders, in a large general population sample derived from the 2001 National Household Survey on Drug Abuse. Analysis examine the demographic characteristics and patterns of substance use disorders among persons with and without a co-occuring serious mental disorder.

Swartz JA; Lurigio AJ. Screening for serious mental illness in populations with co-occurring substance use disorders: Performance of the K6 scale. Journal of Substance Abuse Treatment 31(3): 287-296, 2006. (44 refs.)

Serious mental illnesses (SMIs) such as schizophrenia, bipolar disorder, and major depression are prevalent among individuals with substance use disorders, particularly those in drug treatment programs. No screening tool has yet become the gold standard for identifying SMI among individuals with substance use disorders. One candidate instrument, the K6 screening scale, is brief, easy to administer and score, and has performed well, detecting SMI in studies using general population samples. We used data from the National Survey on Drug Use and Health to examine the K6's psychometric properties in a subsample of persons with substance use disorders and found that the K6 accurately screened for severe psychological distress associated with SMI among individuals with substance use disorders and across different psychiatric disorders.

Swartz MS; Wagner HR; Swanson JW; Stroup TS; McEvoy JP; Canive JM et al. Substance use in persons with schizophrenia: Baseline prevalence and correlates from the NIMH CATIE study. Journal of Nervous and Mental Disease 194(3): 164-172, 2006. (38 refs.)

This study examined baseline correlates of substance use in the NIMH Clinical Antipsychotic Trials of Intervention Effectiveness project. Approximately 60% of the sample was found to use substances, including 37% with current evidence of substance use disorders. Users (with and without substance use disorders), compared with nonusers, were significantly more likely to be male, be African-American, have lower educational attainment, have a recent period of homelessness, report more childhood conduct problems, have a history of major depression, have lower negative symptom and higher positive symptom scores on the Positive and Negative Syndrome Scale, and have a recent illness exacerbation. Individuals with comorbid substance use disorders were significantly more likely to be male, report more childhood conduct problems, have higher positive symptom scores on the Positive and Negative Syndrome Scale, and have a recent illness exacerbation. These analyses suggest that substance use disorders in schizophrenia are especially common among men with a history of childhood conduct disorder problems and that childhood conduct disorder problems are potent risk factors for substance use disorders in schizophrenia.

Tidey JW; Rohsenow DJ; Kaplan GB; Swift RM. Cigarette smoking topography in smokers with schizophrenia and matched non-psychiatric controls. Drug and Alcohol Dependence 80(2): 259-265, 2005. (48 refs.)

Smoking is highly prevalent among people with schizophrenia, and little is known about factors that affect smoking in these patients, One basic question is whether smoking behavior differs for smokers with schizophrenia compared to equally nicotine-dependent smokers who do not have a major mental illness. In this study, 20 smokers with schizophrenia or schizoaffective disorder (SCZ) and 20 non-psychiatric smokers (CON) underwent smoking topography assessments. The groups were matched on a e, gender, daily smoking rate, years of regular smoking and nicotine dependence rating. Results indicate that, compared to the CON participants, the SCZ participants smoked significantly more total puffs (SCZ: 58.5 +/- 48.3: CON: 21.3 +/- 9.4) and puffs per cigarette (SCZ: 12.3 +/- 6.0; CON: 8.9 +/- 2.3) and had shorter inter-puff intervals (SCZ: 21.9 +/- 9.7 s: CON: 42.0 +/- 21.5 s), larger total cigarette puff volumes (SCZ: 583 +/- 169 ml; CON: 429 +/- 159 ml) and higher carbon monoxide boosts (SCZ: 3.8 +/- 5.4 ppm; CON: 1.0 +/- 2.5 ppm). Test-retest reliabilities were good to excellent for most smoking measures in both groups. These findings suggest that smokers with schizophrenia smoke more intensely than matched non-psychiatric smokers and that their smoking behavior is reliable when assessed under laboratory conditions.

Verdoux H; Tournier M; Cougnard A. Impact of substance use on the onset and course of early psychosis. Schizophrenia Research 79(1): 69-75, 2005. (54 refs.)

The strong comorbidity between psychosis and substance use is already identifiable in early psychosis, raising the question of the direction of the association between substance use and psychosis onset. It has long been considered that this association was explained by the self-medication hypothesis. This hypothesis has been recently challenged by several prospective studies carried out in population-based samples, showing a dose-response relationship between cannabis exposure and risk of psychosis. This association was independent from potential confounding factors such as exposure to other drugs and preexistence of psychotic symptoms. As a large percentage of subjects from the general population is now exposed to this drug, even a small increase in the risk of adverse effects may have significant deleterious consequences for the health of the population. Hence, reducing exposure to cannabis may contribute to prevention of some incident cases of psychosis. Regarding prognosis, persistent substance misuse after the onset of psychosis has a deleterious impact on clinical outcome. Therapeutic programs for subjects with dual diagnosis should be implemented early in the course of psychosis to maximise their impact on the course of illness.

Vevera J; Hubbard A; Vesely A; Papezova H. Violent behaviour in schizophrenia: Retrospective study of four independent samples from Prague, 1949 to 2000. British Journal of Psychiatry 187: 426-430, 2005. (27 refs.)

Background: A number of studies have reported increased violence in patients with schizophrenia. Aims To determine the prevalence of violence among those with schizophrenia in samples from 1949,1969,1989 and 2000 in Prague (Czech Republic) and to examine trends in this behaviour. Method: Records from 404 patients meeting DSM-IV criteria for schizophrenia were screened for violence (defined as 3 points on the Modified Overt Aggression Scale) from the first observed psychotic symptoms until the time of latest available information. Results: Logistic regression revealed a marginally significant increase in violence only in the 2000 cohort. Overall, violence was associated with schizophrenia in 41.8% of men and 32.7% of women, with no association between substance misuse and violence. Conclusions: The violence rate found in our sample is expected to remain stable over time under stable conditions. Substance misuse is not the leading cause of violence among those with schizophrenia.

Vornik LA; Brown ES. Management of comorbid bipolar disorder and substance abuse. Journal of Clinical Psychiatry 67(Supplement 7): 24-30, 2006. (64 refs.)

Bipolar disorder is a severe and often chronic disorder with lifetime prevalence rates of bipolar spectrum disorders of up to 6.5% in the general population. Patients with bipolar disorder frequently report co-occurring substance use disorders, and the rates of alcohol and other substance use disorders are significantly higher in persons with bipolar disorder than in the general population. The present review discusses why people with bipolar disorder use substances, provides an overview of the impact of alcohol and other substance use on the course of bipolar disorder, and outlines the treatment options currently available to patients with co-occurring bipolar disorder and substance abuse. Our aim is to summarize the existing data on the pharmacologic treatment options and to include the most recent published data whenever possible. Three randomized, placebo-controlled studies of dual-diagnosis patients treated with carbamazepine, lithium, and valproate are discussed. The results are generally positive and support the use of these agents in dual-diagnosis patients. Open-label studies are also presented, and the need for controlled data is outlined. The review also briefly discusses the psychotherapeutic approaches to patients with comorbid bipolar and substance use disorders.

Weiser M; Davidson M; Noy S. Comments on risk for schizophrenia. Schizophrenia Research 79(1): 15-21, 2005. (66 refs.)

Recent developments have significantly furthered understanding of genetic and environmental factors affecting risk for schizophrenia. Environmental effects, such as immigration, living in a city, and substance abuse have been found to be associated with later schizophrenia. Although the highest risk for schizophrenia is still having a monozygotic twin with schizophrenia (50%), the candidate genes claimed to be associated to date only yield a very small excess risk and all of these effects (environmental and genetics) increase the risk for schizophrenia by only 2-3 fold. Thus, given the low prevalence of the disorder in the general population (0.5-1%), they are not practical in predicting future illness. One possible strategy to make the currently known risk factors for schizophrenia more useful clinically is based on findings indicating that many of the genetic and environmental risks cited above are not specific for schizophrenia, but increase risk for psychopathology in general. As up to 50% of the general population will be affected during their lifetime by a condition defined in DSM IV as psychopathology, due to this much higher base rate, factors increasing risk by 2-3 fold might become clinically relevant.

Westermeyer J. Comorbid schizophrenia and substance abuse: A review of epidemiology and course. (review). American Journal on Addictions 15(5): 345-355, 2006. (99 refs.)

Over the last dozen years, our knowledge regarding comorbid schizophrenia (SCZ) and substance use disorder (SUD) has evolved in several ways. First, the rate of lifetime comorbid SCZ-SUD appears to have increased another 20-30%, so now about 70-80% of persons with SCZ have lifetime SUD. Second, early remission of SUD has become commonplace among patients with SCZ, perhaps outnumbering the number of SCZ-only patients as well as those with active SCZ-SUD. Third, sustained SUD remission is well demonstrated, though the rates may yet be low. Fourth, research on comorbid SCZ-SUD is filling out our knowledge in many areas, including the characteristics of SCZ patients at risk for SUD, reasons SCZ patients seek out substances, effects of various substances on SCZ course and symptoms, and obstacles to SUD recovery in people with SCZ. The influence of SUD treatment and self-help on epidemiology and course has not been adequately evaluated. Primary prevention and early treatment of SUD in SCZ patients are still relatively neglected, though they offer our greatest hope for enhancing the lives of people with SCZ and improving the cost efficacy of care.

Whitty P; Clarke M; McTigue O; Browne S; Kamali M; Larkin C et al. Diagnostic stability four years after a first episode of psychosis. Psychiatric Services 56(9): 1084-1088, 2005. (25 refs.)

Objective: The objective of this study was to determine the stability of a diagnosis of psychosis four years after the first-episode diagnosis. Methods: The study was a prospective four-year follow-up study (1995 to 1999) of 147 patients with schizophrenia, affective disorder, and other psychoses who presented with a first episode of psychosis in an epidemiologic catchment area in Ireland. All diagnoses were made on the basis of the Structured Clinical Interview for DSM-IV. Results: One quarter of the patients evidenced a change in diagnosis at follow-up. The most common change was to a diagnosis of schizophrenia. The positive predictive values of schizophrenia and bipolar affective disorder were 97 percent and 80 percent, respectively. Fewer years spent in education, lower levels of initial psychopathology, and presence of comorbid alcohol or substance abuse were associated with change in diagnosis at follow-up. Conclusions: Among the diagnoses studied, schizophrenia was the most stable diagnosis after four years. The greatest instability occurred in the categories of drug-induced psychosis and psychosis not otherwise specified.

Willenbring ML. Integrating care for patients with infectious, psychiatric, and substance use disorders: Concepts and approaches. AIDS 19(Supplement 3): S227-S237, 2005. (140 refs.)

Patients with chronic viral infections such as HIV/AIDS or hepatitis C often have multiple co-existing problems such as psychiatric and addictive disorders, as well as social problems such as lack of housing, transportation and income that present challenging obstacles to successful management. Because services for these different problems are usually provided by different disciplines in varying locations, fragmentation of care can lead to treatment dropouts, lack of adherence, and poor outcomes. Integration strategies, ranging from simple efforts to improve communication and coordinate care to fully integrated multidisciplinary teams have been used to improve disease management. Although evidence for effectiveness is comprised primarily of observational studies of demonstration programmes, integration may be desirable on a pragmatic basis alone. Quality improvement strategies are attractive vehicles for implementing care integration and measuring its impact. Careful assessment of the problem to be solved and the development of targeted strategies will maximize chances of a successful outcome.

Williams JM; Ziedonis DM; Abanyie F; Steinberg ML; Foulds J; Benowitz NL. Increased nicotine and cotinine levels in smokers with schizophrenia and schizoaffective disorder is not a metabolic effect. Schizophrenia Research 79(2-3): 323-335, 2005. (48 refs.)

it has been hypothesized that smokers with schizophrenia take in more nicotine per cigarette than smokers without this disorder. This study examines this phenomenon by comparing the serum nicotine and cotinine levels in smokers with either schizophrenia or schizoaffective disorder compared to control smokers without mental illness. Serum cotinine and nicotine levels of smokers with schizophrenia or schizoaffective disorder were 1.3 times higher than control smokers (cotinine 291 versus 227 ng/mL; p=0.0115; nicotine 28 versus 21 ng/mL; p<0.001) despite smoking a similar number of cigarettes per day. Similar serum 3'-hydroxycotinine (3HC) to cotinine ratios in both groups indicate that this difference was not due to differences in the rate of metabolism of nicotine or cotinine. By examining serum nicotine and 3HC/cotinine ratios in addition to cotinine, this study expands upon previous research that relied on cotinine as an indirect indicator for nicotine intake. Our data support the hypothesis that the increased serum nicotine and cotinine levels observed are attributable to an increased nicotine intake per cigarette in smokers with schizophrenia as compared to those without mental illness.

Xie HY; McHugo GJ; Fox MB; Drake RE. Substance abuse relapse in a ten-year prospective follow-up of clients with mental and substance use disorders. Psychiatric Services 56(10): 1282-1287, 2005. (40 refs.)

Objectives: This study addressed the rate and predictors of substance abuse relapse among clients with severe mental illness who had attained full remission from substance abuse. Methods: In a ten-year prospective follow-up study of clients with co-occurring severe mental and substance use disorders, 169 clients who had attained full remission, defined according to DSM-III-R as at least six months without evidence of abuse or dependence, were identified. The Kaplan-Meier survival curve was developed to show the pattern of relapse, and a discrete-time survival analysis was used to identify predictors of relapse. Results: Approximately one-third of clients who were in full remission relapsed in the first year, and two-thirds relapsed over the full follow-up period. Predictors of relapse included male sex, less than a high school education, living independently, and lack of continued substance abuse treatment. Conclusions: After attaining full remission, clients with severe mental disorders continue to be at risk of substance abuse relapse for many years. Relapse prevention efforts should concentrate on helping clients to continue with substance abuse treatment as well as on developing housing programs that promote recovery.

Xie HY; McHugo GJ; Helmstetter BS; Drake RE. Three-year recovery outcomes for long-term patients with co-occurring schizophrenic and substance use disorders. Schizophrenia Research 75(2-3): 337-348, 2005. (55 refs.)

Little is known about the expected treatment outcomes of patients with co-occurring schizophrenic and substance use disorders. This paper reports 3-year outcomes for 152 patients with schizophrenia or schizoaffective disorder and substance use disorders, all of whom received integrated dual disorders treatments in the New Hampshire Dual Diagnosis Study. Outcomes are defined as positive coping behaviors identified by consumers as indicators of recovery. Participants improved steadily in terms of controlling symptoms of schizophrenia, actively attaining remissions from substance abuse, increasing competitive employment, increasing social contacts with non-substance abusers, and improving life satisfaction. Though successful in reducing hospitalization and homelessness, they did not increase time in independent living situations. Outcomes were only weakly interrelated, suggesting that recovery is a multidimensional concept. Neither psychotic diagnosis (schizophrenia vs. schizoaffective disorder) nor substance abuse diagnosis (alcohol vs. other drug disorder vs. both) was related to outcomes. However, these patients with co-occurring schizophrenic and substance use disorders did significantly less well than patients with co-occurring bipolar and substance use disorders in terms of hospitalization, independent living, and quality of life. Overall, the findings provide a hopeful long-term perspective for dual diagnosis patients.

Zhang AY; Harmon JA; Werkner J; McCormick RA. The long-term relationships between the motivation for change and alcohol use severity among patients with severe and persistent mental illness. Journal of Addictive Diseases 25(1): 121-128, 2006. (37 refs.)

This study examined the long-term relationship of changes in the motivation to remedy alcohol abuse to alcohol use severity among patients with a dual diagnosis of substance abuse disorder and severe and persistent mental illness. Linear regression analyses showed that patients who increasingly recognized alcohol use problems over a 9-month period exhibited significantly greater alcohol use severity at 9 months and a significant increase in alcohol use severity over time. Moreover, patients who became increasingly determined to take actions against alcohol use over a 9-month period exhibited significantly lower alcohol use severity at 9 months and a significant decrease in alcohol use severity over time. The findings support Prochaska////'s transtheoretical model of the motivation for change. They suggest that the recognition of alcohol use problems comes along with learning adverse consequences of alcohol use and that increased determination to take actions is critical to the long-term behavioral changes in alcohol use.